Injectable non-surgical dermal fillers have been used since the 1990s.
A common use of fillers is to address the facial structure changes that occur with aging.
These changes include the following (Clark et al., 2023; Fanian et al., 2023; Wongprasert et al., 2022):
- Resorption of facial bone and bony prominences
- Weakening of facial tissue retaining ligaments
- Reductions in facial subcutaneous fat leading to a thinning of the skin volume and texture
- Segmentation of the facial compartments instead of a smooth, continuous skin tone, appearance, and texture
- Damage to the skin cells and substrate tissue
- Effects of gravity on skin as it loses its supportive structure leading to descent/ droop of facial fatty compartments
- Skin dryness, flaking, increased wrinkling, and skin roughness
Effects visually include a deflated skin appearance, deepening nasal labial folds, drooping of the jowls, and creation of an “inverted triangle” appearance to the face.
While not inherently harmful, these changes reflective of tissue aging can be distressing for individuals.
How dermal fillers can address the facial changes associated with aging
As we age, the face increasingly compartmentalizes, with creases becoming more prominent and the facial appearance becoming less smooth in transitions.
More than 3 million dermal filler facial procedures are conducted annually in the United States alone–second only to neurotoxin therapies such as Botox/ Xeomin/ Daxxify, etc. (Clark et al., 2023).
Dermal fillers replace lost volume, such as in the cheek bone region, in the nasal labial region, the lips, around the mouth, along the chin, in the temple regions, and under the eyes.
Dermal fillers can also be used to smooth out deep wrinkles and creases, providing a smoother continuous skin surface appearance.
What types of fillers are available?
Hyaluronic acid is popular as it is affordable, and can be locally dissolved if necessary. It is naturally found in the body.
Hyaluronic acid
The most popular filler is hyaluronic acid. Hyaluronic acid is a polysaccharide that is abundant in the connective tissues making up the extracellular matrix (Wongprasert et al., 2022).
Because hyaluronic acid is found naturally in the body, it has a low stimulatory effect on the immune system and therefore, is generally well tolerated (Clark et al., 2022).
Hyaluronic acid fillers have the advantage of being dissolvable using hyaluronidase (Clark et al., 2023). Additionally, they are temporary, lasting generally 6 months to 12 months. Some clients feel more at ease knowing that the modifications to their appearance are not permanent.
The hyaluronic acid used in filler procedures is modified with cross linking technology to produce greater stability and firmness–different levels of firmness are utilized based on the area of the face that is being treated (Clark et al., 2023).
Hyaluronic acid fillers also pull water into the gel to provide greater volume, though this varies by product.
Other fillers
Other filler products include human, bovine, and porcine collagen–these can cause skin reactions and skin testing must be performed prior to filler application (Clark et al., 2023).
Sculptra stimulates collagen production and can have a profound effect on facial fullness. Additionally, it is used to smooth out areas with cellulite. It is longer lasting, up to 2 years (Clark et al., 2023).
Calcium hydroxyapatite offers a semi-permanent solution as a filler. It is more prone to promoting nodule formation and it is not recommended for lips or around the eyes. It does stimulate collagen production (Clark et al., 2023).
Fat transfers use a person’s own fat which is harvested from a donor site such as the abdomen, flank, or thigh. It is considered a permanent solution, and a person’s fat is considered one of the most natural solutions as it utilizes the body’s own tissue. The fat tissue can also contribute to regeneration of local tissues due to stem cell presence (Clark et al., 2023).
Polymethylmethacrylate (PMMA) is another “permanent” option (lasts around 5 years). Because it contains bovine collagen skin testing is required prior to the filler procedure (Clark et. al., 2023).
How safe are dermal fillers?
A working knowledge of facial anatomy and regions of risk along with technique is key to reduce the risk of complications.
Dermal fillers tend to be well tolerated, with serious vascular side effects occurring at an estimated 1 in 2000 to 1 in 10000 procedures (Shelke et al., 2020). There are several risks and complications associated with dermal fillers that patients need to be aware of, prior to consenting to a procedure.
These risks/ complications include (Kroumpouzos & Treacy, 2024):
- Nodule (lump) formation
- Misplacement
- Migration (movement of filler from desired area to an adjacent area with undesired esthetic effects
- Infection
- Vascular occlusions
- Vascular embolisms
Due to the dissolvability of hyaluronic acid, it remains a great option as concerns about migration, nodule formation, and misplacement can be addressed with hyaluronidase.
Vascular occlusions and vascular emboli are the most concerning of filler complications, but are thankfully uncommon (Hong et al., 2024).
Arterial complications occur when the filler is inadvertently injected into an artery, or swelling from filler compresses an artery. Complications can include (Hong et al., 2024):
- Skin and facial tissue necrosis (death) in the tissues fed by the blocked artery
- Emboli from dermal filler injected in arteries can travel to places such as the eye leading to blindness or into the cerebral artery causing a stroke
Highest injection risk areas for emboli include the region between the eye brows, immediately under the eyes, the forehead, and the nasal labial fold region. Care must be taken to inject the filler without excessive pressure, and at the appropriate depths to minimize risks.
Venous complications include pulmonary embolism from filler emboli injected into the vein, with the highest injection risk area being in the temple region (Hong et al., 2024).
Hyaluronidase can be used along with massage to break down filler in cases of blood vessel compression and tissue ischemia (Hong et al., 2024). Hyaluronidase also can move through blood vessel walls to help break down filler that has made its way into blood vessels (Hong et al., 2024).
For other fillers, reversal requires physical removal of the filler using lancing, syringes, or surgical techniques (Hong et al., 2024). This is why hyaluronic acid tends to be a better choice for those concerned about placement or vascular complications.
Is a dermal filler treatment a good option for me? How can I ensure the best outcomes of treatment?
Most people can tolerate filler treatment with minimal side effects or complications. Precautions must be taken if certain illnesses are present.
Determination of whether a dermal filler treatment is a good option to address problematic or distressing skin/ facial structure features involves consultation with a skilled provider.
However, there are some considerations that may help you decide whether or not filler is right for you.
It is important to disclose any prior cosmetic treatments with your provider at the time of consultation for your dermal filler (De Boulle & Heydenrych, 2015).
Generally, the following conditions would be considered contraindications or a precaution prior to considering dermal filler treatment (De Boulle & Heydenrych, 2015):
- Active infection, particularly in desired treatment area or involving dental, ear, nose, or throat regions, including herpes and HPV
- Active rosacea acne
- Active inflammatory skin condition
- Autoimmune conditions such as Crohn’s disease, ulcerative colitis, or active collagenosis diseases such as lupus, scleroderma, or rheumatoid arthritis
- HIV
- Milasma/ post inflammatory hyperpigmentation
- Anticoagulant therapy
- History of multiple or severe allergic reactions
- Very thin skin, skin atrophy, such as seen with prolonged corticosteroid therapy, in the undereyes or cheeks when areas present with numerous fine lines and wrinkles indicating atrophy
- Dental procedures are to be avoided 2 weeks before or after dermal filler procedures
Summary
Dermal fillers address the loss of facial tissues that naturally occur due to aging. By replacing lost volume, clients can experience fuller cheeks, smooth out deep creases, smooth out the jawline, and help bring a smoother, more youthful appearance to the face.
While there are risks associated with dermal fillers, complications are rare. Further, use of proper techniques paired with knowledge of facial anatomy/ high risk regions is essential for providers to minimize risk.
How Lancaster Wellness can help
Dr. Ruziev trained on filler placement under the supervision of a plastic surgeon in 2020, and obtained certification from the American Academy of Facial Esthetics for advanced filler techniques.
He has treated clients addressing their dermal filler needs at Lancaster Wellness since 2021 and has provided direct supervision and training to his office staff concerning proper filler injection techniques, precautions, and in the use of hyaluronidase when appropriate.
Feel free to contact us with any questions, book a free consultation either online or by calling our office at 717-297-7900.
Look your best, feel your best, live well!!
Article by Donovan Carper MSN RN CPT CHC
References
Clark, N. W., Pan, D. R., & Barrett, D. M. (2023). Facial fillers: Relevant anatomy, injection techniques, and complications. World journal of otorhinolaryngology – head and neck surgery, 9(3), 227–235. https://doi.org/10.1002/wjo2.126
De Boulle, K., & Heydenrych, I. (2015). Patient factors influencing dermal filler complications: prevention, assessment, and treatment. Clinical, cosmetic and investigational dermatology, 8, 205–214. https://doi.org/10.2147/CCID.S80446
Fanian, F., Deutsch, J. J., Bousquet, M. T., Boisnic, S., Andre, P., Catoni, I., Beilin, G., Lemmel, C., Taieb, M., Gomel-Toledano, M., Issa, H., & Garcia, P. (2023). A hyaluronic acid-based micro-filler improves superficial wrinkles and skin quality: a randomized prospective controlled multicenter study. The Journal of dermatological treatment, 34(1), 2216323. https://doi.org/10.1080/09546634.2023.2216323
Hong, G. W., Hu, H., Chang, K., Park, Y., Lee, K. W. A., Chan, L. K. W., & Yi, K. H. (2024). Adverse Effects Associated with Dermal Filler Treatments: Part II Vascular Complication. Diagnostics (Basel, Switzerland), 14(14), 1555. https://doi.org/10.3390/diagnostics14141555
Kroumpouzos, G., & Treacy, P. (2024). Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations. JMIR dermatology, 7, e50403. https://doi.org/10.2196/50403
Schelke, L., Decates, T., Kadouch, J., & Velthuis, P. (2020). Incidence of Vascular Obstruction After Filler Injections. Aesthetic surgery journal, 40(8), NP457–NP460. https://doi.org/10.1093/asj/sjaa086
Wongprasert, P., Dreiss, C. A., & Murray, G. (2022). Evaluating hyaluronic acid dermal fillers: A critique of current characterization methods. Dermatologic therapy, 35(6), e15453. https://doi.org/10.1111/dth.15453